Patient Intake

Please complete this form for each patient you've booked Dr. Arce to provide BOTH surgical and sedation services for. You only need to submit this once per patient.

Sedation fees — paid in full directly to In-Office Specialist LLC. No insurance billing, no percentage deductions: the fee listed is what Dr. Arce receives.

Oral sedation — $500
Moderate IV sedation — $2,000 (up to 4 hours)

Payment via Zelle: 281-760-9270

OfficeOffice name *Your email (office contact) *We'll use this for any follow-ups about this patient.

PatientPatient's full name *Patient's date of birth *Patient's phone number *Patient's email *

Surgical procedureWhat surgical procedure do you need Dr. Arce to perform? *

ProcedureSedation type *Who is responsible for the bill? *

Visit duration

Half day (4 hours — one AM or PM slot)Full day (8 hours — book both AM and PM)

Picking Full day changes the confirmation email so you're reminded to book both slots on the calendar.

You'll pick the appointment date/time on Dr. Arce's calendar after submitting this form.

ClinicalPatient allergies *Preferred pharmacy *Medical history (PDF, up to 5 files, 50 MB each) *Files upload directly to Dr. Arce's secure Drive folder; no patient data passes through this site's server.